1871658278 NPI number — KEITH MARK GROSS MD INC

Table of content: STAFFORD VAIL STEVENS RN (NPI 1932365855)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871658278 NPI number — KEITH MARK GROSS MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEITH MARK GROSS MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871658278
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 51197
Provider Second Line Business Mailing Address:
DEPT 1401
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90051-5497
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15247 11TH ST
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
VICTORVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92395-3727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-335-8638
Provider Business Practice Location Address Fax Number:
909-335-8644
Provider Enumeration Date:
12/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GROSS
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
909-335-8638

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  G63544 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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